Arthroplasty care redesign related to the Comprehensive Care for Joint Replacement model: results at a tertiary academic medical center

Reversal of the Halo Effect: Prolonged Participation in Comprehensive Care for Joint Replacement Negatively Impacts Revision Metrics

Background

The downstream regional effect of the Comprehensive Care for Joint Replacement (CJR) program on care pathway-adjacent patients, including revision arthroplasty patients, is poorly understood. Prior studies have demonstrated that care pathways targeting primary total joint arthroplasty may produce a halo effect, impacting more complex patients with parallel care pathways. However, neither the effect of regional referral changes from CJR nor the durability of these positive changes with prolonged bundle participation has been assessed.

Methods

Blinded data were pulled from electronic medical records. Primary analyses focused on the effect of CJR participation from 2015 (baseline) to 2020 (final participation year) at a tertiary care safety-net hospital. Patient demographics were evaluated using multivariate analysis of variance and chi-square calculations between procedure types over time.

Results

Patients who underwent revision total knee arthroplasty (N = 376) and revision total hip arthroplasty (N = 482) were included. More patients moved through the revision-care pathway over the participation period, with volume increasing by 42% over time. Patients became more medically complex: the Charlson comorbidity index increased from 3.91 to 4.65 (P = .01). The mean length of stay decreased from 5.14 days to 4.50 days (P = .03), but the all-cause complication (8.3%-15.2%; P = .02) and readmission rates (13.6%-16.6%; P = .19) increased over time.

Conclusions

Despite care pathway improvements over 5 years of CJR participation, revision patients did not display clear benefits in quality metrics but demonstrated a considerable increase in volume and medical complexity over time. The care of these patients may supersede even thoughtfully implemented care pathways, especially when referral burden increases, as may be prone to happen in regional, financial risk-conferring value-based programs. Understanding the impact of mandatory bundled payment programs like CJR on the care of arthroplasty patients regionally will be essential as value-based programs evolve.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Payer Status and Medication Management-Part Six of the Movement Is Life Special ONJ Series

This article is the sixth in the Movement is Life series and focuses on insurance coverage and medication management in the perioperative period, 2 tangentially related variables that affect patient outcomes. Our aim is to use current practices and literature to develop recommendations for nurse navigators' execution of preoperative optimization protocols related to payer status and medication management. Discussions with nurse navigators and a literature search were used to gather information and develop recommendations specific to optimizing payer status and medication management. Nurse navigators connected patients to resources and provided education regarding financial concerns and medications, and findings from the literature discussed insurance status among TJA patients. Nurse navigators can contribute to payer status and medication management optimization by providing patient education and resource referrals. In addition, we recommend conducting repeated medication reconciliation and developing awareness of financial resources and perioperative medication management guidelines.

Impact of the Comprehensive Care for Joint Replacement Bundled Payment Model on Postoperative Utilization of Home Health and Outpatient Physical Therapy Services

OBJECTIVE

To study the effect of the Comprehensive Care for Joint Replacement (CJR) bundled payment program on postoperative home health and outpatient physical therapy (PT) for total hip or knee arthroplasty (THA/TKA).

DESIGN

Retrospective cohort with national Medicare data (5% claims) using a difference-in-differences analysis comparing January 2013-September 2015 (before) versus October 2016-September 2019 (after).

SETTING

Administrative claims from hospitals in 34 metropolitan statistical areas with mandatory CJR participation as of 2018 and 42 control metropolitan statistical areas.

PARTICIPANTS

Episodes in fee-for-service Medicare beneficiaries (5% claims) undergoing elective THA (n=6327) or TKA (n=10,764) with community discharge.

INTERVENTIONS

Implementation of CJR bundled payment program.

MAIN OUTCOME MEASURES

Home health and outpatient PT, including any use and number of visits.

RESULTS

Program implementation was associated with an increased percentage of THA episodes using home health PT (+8.0 percentage-point change; 95% CI, +3.5 to +12.6; P=.001) but a decreased per-episode number of home health PT visits for THA (-1.1; 95% CI, -1.6 to -0.6; P<.001) and TKA (-1.1; 95% CI, -1.4 to -0.7; P<.001). The program was also associated with an increased per-episode number of outpatient PT visits for TKA in the primary but not sensitivity analyses (+0.8; 95% CI, +0.1 to +1.4; P=.02).

CONCLUSIONS

Findings of increased home health PT may reflect an intentional shift in care from the inpatient postacute setting to the community to decrease costs. Alternatively, the limited effect of CJR, particularly on outpatient PT, could reflect challenges with care coordination in a retrospective bundle spanning multiple care settings.

Did the Comprehensive Care for Joint Replacement Bundled Payment Program Impact Sex Disparities in Total Hip and Knee Arthroplasties?

BACKGROUND

Sex disparities have been noted across various aspects of total hip/knee arthroplasty (THA/TKA). Given incentives to standardize care, bundled payment initiatives including the Comprehensive Care for Joint Replacement (CJR) program may reduce disparities. This study aimed to assess the CJR program's impact on sex disparities in THA/TKA care and outcomes.

METHODS

This retrospective cohort study included 259,673 THAs (61.7% women) and 506,311 TKAs (64.0% women) from a large national database (2013 to 2017). Sex disparities were assessed for care and outcomes related to the period (1) before surgery, (2) during hospitalization for THA/TKA, and (3) after discharge. Disparities were reported as women:men ratios. Difference-in-differences analyses estimated the impact of the CJR program on pre-existing sex disparities.

RESULTS

For both THA and TKA, women were less likely than men to present with a Charlson-Deyo comorbidity index >0 (women:men ratio 0.88 to 0.92), but were more likely to require blood transfusions (women:men ratio 1.48 to 1.79) and be discharged to institutional postacute care (women:men ratio 1.50 to 1.66). Difference-in-differences models demonstrated that the CJR bundled payment program reduced sex disparities in institutional postacute care discharges (THA: -2.28%; 95% confidence interval [CI] -4.20 to -0.35%, P = .02; TKA: -2.07%; 95% CI -3.93 to -0.20%; P = .03) and THA 90-day readmissions (-1.00%, 95% CI -1.88 to -0.13%, P = .02), indicating a differential impact of CJR in women versus men for some outcomes.

CONCLUSIONS

While sex disparities in THA/TKA persist, the CJR program demonstrates potential to impact such differences. Future research should focus on how potential mechanisms could be leveraged to reduce disparities.

Use of interrupted time-series analyses in evaluating health economic outcomes following implementation of multilayer water-tight wound closure in a primary total joint arthroplasty population

Aim: Total joint arthroplasty (TJA) with multi-layer, watertight closure (MLWC) using knotless barbed suture and 2-octyl cyanoacrylate plus polymer mesh tape was compared with conventional closure (CC) using Vicryl™ sutures and staples. Patients & methods: Electronic medical records of patients undergoing TJA (1574: total knee arthroplasty; 580: total hip arthroplasty; 13: unknown) from a single surgeon at a US hospital (CC 2011 to 2013; MLWC 2015 to 2020) were reviewed. Outcomes were length of stay (LOS), discharge to skilled nursing facility (SNF), 90-day surgical site infection (SSI) and 90-day readmission. Logistic regression controlled for baseline characteristics. Adjusted interrupted time series (ITS) analyses accounted for decreasing trends in LOS and SNF discharge over time. Results: Among 2167 TJA cases (mean [standard deviation] age 66.0 [9.7] years, 53.3% female), 906 received CC and 1261 received MLWC. Bivariate analysis showed no statistically significant differences in 90-day SSI rates; however, MLWC patients had 60% lower 90-day readmission rates (1.5 vs 3.8%, p < 0.05), 44% lower LOS (1.4 vs 2.5 days, p < 0.05) and 40% lower discharge rates to a skilled care facility (8.5 vs 14.1%, p < 0.05). Multivariable analyses showed CC patients were 2.45-times more likely to be readmitted within 90 days, 1.88-times more likely to be discharged to SNF and had 1.67-times longer LOS compared with MLWC. ITS analyses showed a sharp decline in LOS (0.9 days) and discharge to SNF (5.6% incidence) after implementation of MLWC, followed by no further changes for the remainder of the study period. Conclusion: MLWC was associated with ≥40% reduction in 90-day readmission, LOS and SNF discharge compared with TJA CC. LOS and discharge rate to SNF declined sharply after the implementation of MLWC.

Pre-COVID-19 hospital quality and hospital response to COVID-19: examining associations between risk-adjusted mortality for patients hospitalised with COVID-19 and pre-COVID-19 hospital quality

OBJECTIVES

The extent to which care quality influenced outcomes for patients hospitalised with COVID-19 is unknown. Our objective was to determine if prepandemic hospital quality is associated with mortality among Medicare patients hospitalised with COVID-19.

DESIGN

This is a retrospective observational study. We calculated hospital-level risk-standardised in-hospital and 30-day mortality rates (risk-standardised mortality rates, RSMRs) for patients hospitalised with COVID-19, and correlation coefficients between RSMRs and pre-COVID-19 hospital quality, overall and stratified by hospital characteristics.

SETTING

Short-term acute care hospitals and critical access hospitals in the USA.

PARTICIPANTS

Hospitalised Medicare beneficiaries (Fee-For-Service and Medicare Advantage) age 65 and older hospitalised with COVID-19, discharged between 1 April 2020 and 30 September 2021.

INTERVENTION/EXPOSURE

Pre-COVID-19 hospital quality.

OUTCOMES

Risk-standardised COVID-19 in-hospital and 30-day mortality rates (RSMRs).

RESULTS

In-hospital (n=4256) RSMRs for Medicare patients hospitalised with COVID-19 (April 2020-September 2021) ranged from 4.5% to 59.9% (median 18.2%; IQR 14.7%-23.7%); 30-day RSMRs ranged from 12.9% to 56.2% (IQR 24.6%-30.6%). COVID-19 RSMRs were negatively correlated with star rating summary scores (in-hospital correlation coefficient -0.41, p<0.0001; 30 days -0.38, p<0.0001). Correlations with in-hospital RSMRs were strongest for patient experience (-0.39, p<0.0001) and timely and effective care (-0.30, p<0.0001) group scores; 30-day RSMRs were strongest for patient experience (-0.34, p<0.0001) and mortality (-0.33, p<0.0001) groups. Patients admitted to 1-star hospitals had higher odds of mortality (in-hospital OR 1.87, 95% CI 1.83 to 1.91; 30-day OR 1.46, 95% CI 1.43 to 1.48) compared with 5-star hospitals. If all hospitals performed like an average 5-star hospital, we estimate 38 000 fewer COVID-19-related deaths would have occurred between April 2020 and September 2021.

CONCLUSIONS

Hospitals with better prepandemic quality may have care structures and processes that allowed for better care delivery and outcomes during the COVID-19 pandemic. Understanding the relationship between pre-COVID-19 hospital quality and COVID-19 outcomes will allow policy-makers and hospitals better prepare for future public health emergencies.

Machine Learning-Based Predictive Models for 90-Day Readmission of Total Joint Arthroplasty Using Comprehensive Electronic Health Records and Patient-Reported Outcome Measures

Background

The Centers for Medicare & Medicaid Services currently incentivizes hospitals to reduce postdischarge adverse events such as unplanned hospital readmissions for patients who underwent total joint arthroplasty (TJA). This study aimed to predict 90-day TJA readmissions from our comprehensive electronic health record data and routinely collected patient-reported outcome measures.

Methods

We retrospectively queried all TJA-related readmissions in our tertiary care center between 2016 and 2019. A total of 104-episode care characteristics and preoperative patient-reported outcome measures were used to develop several machine learning models for prediction performance evaluation and comparison. For interpretability, a logistic regression model was built to investigate the statistical significance, magnitudes, and directions of associations between risk factors and readmission.

Results

Given the significant imbalanced outcome (5.8% of patients were readmitted), our models robustly predicted the outcome, yielding areas under the receiver operating characteristic curves over 0.8, recalls over 0.5, and precisions over 0.5. In addition, the logistic regression model identified risk factors predicting readmission: diabetes, preadmission medication prescriptions (ie, nonsteroidal anti-inflammatory drug, corticosteroid, and narcotic), discharge to a skilled nursing facility, and postdischarge care behaviors within 90 days. Notably, low self-reported confidence to carry out social activities accurately predicted readmission.

Conclusions

A machine learning model can help identify patients who are at substantially increased risk of a readmission after TJA. This finding may allow for health-care providers to increase resources targeting these patients. In addition, a poor response to the "social activities" question may be a useful indicator that predicts a significant increased risk of readmission after TJA.

Orthopaedic Nurse Navigators and Total Joint Arthroplasty Preoperative Optimization: Substance Use

Substance use is one of the most common risk factors contributing to complications following total joint arthroplasty. Preoperative optimization programs can help patients modify or stop substance use. The purpose of this study was to provide recommendations and resources that will help nurse navigators standardize and improve preoperative optimization protocols regarding substance use. In a semistructured format, we asked nurse navigators how smoking, alcohol use, and opioid use were addressed. We conducted a literature review and combined findings with nurse navigator reports to create practice recommendations. We recommend consistently referring patients who smoke to smoking cessation programs; using validated screening tools to evaluate alcohol use and involving internists in caring for patients at risk for withdrawal; and involving pain specialists and local resources to assist patients who use opioids. There is a breadth of resources for managing substance use that nurse navigators can utilize to support stronger and more consistent preoperative optimization protocols.

Preoperative Prediction and Risk Factor Identification of Hospital Length of Stay for Total Joint Arthroplasty Patients Using Machine Learning

Background

The aim of this study was to improve understanding of hospital length of stay (LOS) in patients undergoing total joint arthroplasty (TJA) in a high-efficiency, hospital-based pathway.

Methods

We retrospectively reviewed 1401 consecutive primary and revision TJA patients across 67 patient and preoperative care characteristics from 2016 to 2019 from the institutional electronic health records. A machine learning approach, testing multiple models, was used to assess predictors of LOS.

Results

The median LOS was 1 day; outpatients accounted for 16.5%, 1-day inpatient stays for 38.0%, 2-day stays for 26.4%, and 3-days or more for 19.1%. Patients characteristically fell into 1 of 3 broad categories that contained relatively similar characteristics: outpatient (0-day LOS), short stay (1- to 2-day LOS), and prolonged stay (3 days or greater). The random forest models suggested that a lower Risk Assessment and Prediction Tool score, unplanned admission or hospital transfer, and a medical history of cardiovascular disease were associated with an increased LOS. Documented narcotic use for surgery preparation prior to hospitalization and preoperative corticosteroid use were factors independently associated with a decreased LOS.

Conclusions

After TJA, most patients have either an outpatient or short-stay hospital episode. Patients who stay 2 days do not differ substantially from patients who stay 1 day, while there is a distinct group that requires prolonged admission. Our machine learning models support a better understanding of the patient factors associated with different hospital LOS categories for TJA, demonstrating the potential for improved health policy decisions and risk stratification for centers caring for complex patients.

Does value-based healthcare support patient-centred care? A scoping review of the evidence

BACKGROUND

Standardisation of outcome measures is integral to value-based healthcare (VBHC), which may conflict with patient-centred care, focusing on personalisation.

OBJECTIVES

We aimed to provide an overview of measures used to assess the effect of VBHC implementation and to examine to what extent the evidence indicates that VBHC supports patient-centred care.

DESIGN

A scoping review guided by the Joanna Briggs Institute methodology.

SOURCES OF EVIDENCE

We searched the following databases on 18 February 2021: Cochrane Library, EMBASE, MEDLINE and Web of Science.

ELIGIBILITY CRITERIA

We included empirical papers assessing the effect of the implementation of VBHC, published after introduction of VBHC in 2006.

DATA EXTRACTION AND SYNTHESIS

Two independent reviewers double-screened papers and data were extracted by one reviewer and checked by the other. We classified the study measures used in included papers into six categories: process indicator, cost measure, clinical outcome, patient-reported outcome, patient-reported experience or clinician-reported experience. We then assessed the patient-centredness of the study measures used.

RESULTS

We included 39 studies using 94 unique study measures. The most frequently used study measures (n=72) were process indicators, cost measures and clinical outcomes, which rarely were patient-centred. The less frequently used (n=20) patient-reported outcome and experience measures often measured a dimension of patient-centred care.

CONCLUSION

Our study shows that the evidence on VBHC supporting patient-centred care is limited, exposing a knowledge gap in VBHC research. The most frequently used study measures in VBHC research are not patient-centred. The major focus seems to be on measures of quality of care defined from a provider, institution or payer perspective.

Lessons Learned From the Comprehensive Care for Joint Replacement Model at an Academic Tertiary Center: The Good, the Bad, and the Ugly

BACKGROUND

Our institution participated in the Comprehensive Care for Joint Replacement (CJR) model from 2016 to 2020. Here we review lessons learned from a total joint arthroplasty (TJA) care redesign at a tertiary academic center amid changing: (1) CJR rules; (2) inpatient only rules; and (3) outpatient trends.

METHODS

Quality, financial, and patient demographic data from the years prior to and during participation in CJR were obtained from institutional and Medicare reconciled CJR performance data.

RESULTS

Despite an increase in true outpatients and new challenges that arose from changing inpatient-only rules, there was significant improvement in quality metrics: decreased length of stay (3.48-1.52 days, P < .001), increased home discharge rate (70.2-85.5%, P < .001), decreased readmission rate (17.7%-5.1%, P < .001), decreased complication rate (6.5%-2.0%, P < .001), and the Centers for Medicare and Medicaid Services (CMS) Composite Quality Score increased from 4.4 to 17.6. Over the five year period, CMS saved an estimated $8.3 million on 1,486 CJR cases, $7.5 million on 1,351 non-CJR cases, and $600,000 from the voluntary classification of 371 short-stay inpatients as outpatient-a total savings of $16.4 million. Despite major physician time and effort leading to marked improvements in efficiency, quality, and large cost savings for CMS, CJR participation resulted in a net penalty of $304,456 to our institution, leading to zero physician gainsharing opportunities.

CONCLUSION

The benefits of CJR were tempered by malalignment of incentives among payer, hospital, and physician as well as a lack of transparency. Future payment models should be refined based on the successes and challenges of CJR.

Metrics for Monitoring Preoperative Optimization Programs for Total Joint Arthroplasty: A Survey of Orthopaedic Nurses

Preoperative optimization programs are becoming more common for patients seeking total joint arthroplasty; yet, limited research has been conducted to monitor the long-term effects of these programs on patient outcomes. Our aim was to develop a set of metrics that programs can use to monitor the success of preoperative optimization programs. As part of a larger survey of orthopaedic nurses, we collected data regarding current monitoring techniques for preoperative optimization programs and the feasibility of collecting specific variables. Surgical factors such as length of stay and 30-day readmissions were most often used to monitor the success of preoperative optimization programs. Surgical factors were the most likely to be accessible using the electronic medical record. Surgical factors and patient characteristics are the most feasible components for programs to monitor in order to track the outcomes of patients participating in preoperative optimization programs.

How Does the Effect of the Comprehensive Care for Joint Replacement Model Vary Based on Surgical Volume and Costs of Care?

BACKGROUND

The Center for Medicare and Medicaid Innovation revised the comprehensive Care for Joint Replacement (CJR) program, a mandatory 90-day bundled payment for lower extremity joint replacement, in December 2017, retaining 34 of the original 67 metropolitan statistical areas with higher volume and historic episode payments.

OBJECTIVES

We describe differences in costs, quality, and patient selection between hospitals that continued to participate compared with those that withdrew from CJR before and after the implementation of CJR.

RESEARCH DESIGN

We used a triple difference approach to compare the magnitude of the policy effect for elective admissions between hospitals that were retained in the CJR revision or not, before and after the implementation of CJR, and compared with hospitals in nonparticipant metropolitan statistical areas.

SUBJECTS

694,275 Medicare beneficiaries undergoing elective lower extremity joint replacement from January 1, 2013 to August 31, 2017.

MEASURES

The treatment effect heterogeneity of CJR.

RESULTS

Hospitals retained in the CJR policy revision had a greater reduction in 90-day episode-of-care cost compared with those that were allowed to discontinue (-$846, 95% CI: -$1,338, -$435) and had greater cost reductions in the more recent year (2017). We also found evidence that retained CJR hospitals disproportionately reduced treating patients who were older than 85 years.

CONCLUSIONS

Hospitals that continued to participate in CJR after the policy revision achieved a greater cost reduction. However, the cost reductions were partly attributed to avoiding potential higher - cost patients, suggesting that a bundled payment policy might induce disparities in care delivery.

Orthopaedic Nurse Navigator Involvement in Preoperative Optimization for Total Joint Arthroplasty

Patients seeking total joint arthroplasty frequently undergo preoperative optimization with the assistance of nurse navigators to facilitate interactions between patients, consulting services, and the orthopaedic surgical team. Given the enormous impact nurse navigator programs have on reducing postoperative complications, our aim is to characterize the involvement of nurse navigators in preoperative optimization programs across the country. We conducted a survey of nurse navigators identified through the National Association of Orthopaedic Nurses to assess the involvement of nurse navigators in the preoperative optimization process. Sixty-seven percent of responding nurse navigators were involved in preoperative optimization, including components such as heart disease (53%) and poorly controlled diabetes (52%). Orthopaedic nurse navigators are commonly involved in preoperative optimization programs for total joint arthroplasty but most of these involve gated yes/no checklists with limited established referral care pathways. Only some of the programs include standardized referrals for specific medical comorbidities.

Time-Driven Activity-Based Costing in Preoperative Tasks for Total Hip and Knee Arthroplasty

BACKGROUND

Substantial work in the preoperative phase of total hip arthroplasty (THA) and total knee arthroplasty (TKA) is unaccounted for in current Relative Value Scale Update Committee methodology. A Time-Driven Activity-Based Costing (TDABC) analysis allows for an accurate assessment of the preoperative costs associated with total joint replacement surgery.

METHODS

The mean time that clinical staff members spent on preoperative tasks per patient was multiplied by the hourly salary. Clinical staff members included orthopedic surgeons, nurse practitioners or physician assistants, nurses, medical assistants, and surgical coordinators. Mean time spent on preoperative tasks was obtained from the most recent literature. Salaries were obtained from the nationwide database provided by Glassdoor Inc.

RESULTS

Total time spent among clinical staff involved in preoperative tasks for each arthroplasty patient was 8.45 hours (2.96-13.94). Total TDABC was calculated to be $348.17 (132.46-562.64). Accounting for preoperative tasks, the TDABC for TKA/THA increases from $13321.5 to $13669.67. Preoperative tasks are composed of 2.6% of total TKA/THA TDABC. In 2020, an estimated $544,189,710 of preoperative TKA/THA work was completed.

CONCLUSION

Surgeons, providers, and ancillary staff involved in THA/TKA spend a cumulative preoperative work time of approximately 8.5 hours per patient, which equates to $348.17 that is currently unaccounted for in Relative Value Scale Update Committee methodology.

The Spillover Effect of the Medicare Mandatory Bundled Payment Program on Joint Replacement Outcomes: Analysis of Patients with Commercial Insurance and Medicare Advantage

BACKGROUND

To improve the value and efficiency of care among traditional Medicare enrollees, the Centers for Medicare & Medicaid Services has implemented alternative payment models designed to control health-care spending and improve quality. These models may affect care beyond traditional Medicare enrollees, "spilling over" into other populations. Established in April 2016, the Medicare mandatory bundled payment program, called the Comprehensive Care for Joint Replacement (CJR) model, holds hospitals accountable for spending and quality of care for traditional Medicare joint-replacement patients during care episodes that span from the index hospitalization to 90 days post-discharge. We assessed the extent to which the CJR model was associated with outcomes for patients enrolled in commercial insurance and Medicare Advantage plans.

METHODS

With use of Health Care Cost Institute claims data from 2012 through 2017, we assessed the association of the CJR model with total expenditures, discharges to institutional post-acute care, and readmissions among commercial insurance and Medicare Advantage joint-replacement patients. The exposure variable was the implementation of the CJR model in 67 randomly selected metropolitan statistical areas compared with 103 similar areas without CJR implementation. We utilized difference-in-differences models to estimate the spillover effects of the CJR model by comparing outcomes between these areas before and after CJR implementation.

RESULTS

The study included 174,893 joint-replacement episodes of care in commercial insurance enrollees and 202,070 episodes in Medicare Advantage enrollees. Among both commercial insurance and Medicare Advantage enrollees, CJR implementation was associated with no meaningful changes in total episode expenditures, discharges to institutional post-acute care, or readmissions.

CONCLUSIONS

We found no evidence for spillover effects of the CJR model on commercial insurance and Medicare Advantage patients, suggesting that alternative payment models targeting traditional Medicare patients may have limited effects on the cost and quality of care for patients outside of the traditional Medicare system.

National Trends in Post-Acute Care Costs Following Total Hip Arthroplasty from 2010 through 2018

BACKGROUND

Post-acute care remains a target for episode-of-care cost reduction following total hip arthroplasty (THA). The introduction of bundled payment models in the United States in 2013 aligned incentives among providers to reduce post-acute care resource utilization. Institution-level studies have shown increased rates of home discharge with substantial cost savings after adoption of bundled payment models; however, national data have yet to be reported. The purpose of this study was to evaluate national trends in post-acute care utilization and costs following primary THA over the last decade.

METHODS

We reviewed the cases of 189,847 patients undergoing primary THA during 2010 through 2018 from the PearlDiver database. Annual trends in patient demographics, discharge disposition, and post-acute care resource utilization were evaluated. Post-acute care reimbursements were standardized to 2020 dollars and included outpatient visits, prescriptions, physical therapy, home health, inpatient rehabilitation, skilled nursing facilities, and any rehospitalizations or emergency department (ED) visits within 90 days of surgery.

RESULTS

From 2010 to 2018, the mean episode-of-care costs ($31,562 versus $24,188; p < 0.001) and overall post-acute care costs ($5,903 versus $3,485; p < 0.001) both declined. Post-acute care savings were primarily driven by reduced costs of skilled nursing facilities ($1,533 versus $627; p < 0.001), home health ($1,041 versus $763; p = 0.002), inpatient rehabilitation ($949 versus $552; p < 0.001), ED visits ($508 versus $102; p < 0.001), and rehospitalizations ($367 versus $179; p < 0.001). Post-acute care costs declined by $578 (p = 0.025) during 2010 to 2012, $768 (p = 0.038) during 2013 to 2015, and $884 (p = 0.020) during 2016 to 2018.

CONCLUSIONS

Over the last decade, the rate of home discharge after THA increased while rehospitalization and ED visit rates declined, resulting in a substantial decrease in total and post-acute care costs. Post-acute care costs declined most rapidly after the introduction of the new Medicare bundled payment programs in 2013 and 2016.

Patient selection in the Comprehensive Care for Joint Replacement model

OBJECTIVE

To understand whether the Comprehensive Care for Joint Replacement (CJR) program induces participating hospitals to (1) preferentially select lower risk patients, (2) reduce 90-day episode-of-care costs, (3) improve quality of care, and (4) achieve greater cost reduction during its second year, when downside financial risk was applied.

DATA SOURCES

We identified beneficiaries of age 65 years or older undergoing hip or knee joint replacement in the 100% sample of Medicare fee-for-service inpatient (Part A) claims from January 1, 2013 to August 31, 2017. Cases were linked to subsequent outpatient, Part B, home health agency, and skilled nursing facility claims, as well as publicly available participation status for CJR.

STUDY DESIGN

We estimated the effect of CJR for hospitals in the 67 metropolitan statistical areas (MSA) selected to participate in CJR (785 hospitals), compared to those in 104 non-CJR MSAs (962 hospitals; maintaining fee-for-service). A difference-in-differences approach was used to detect patient selection, as well as to compare 90-day episode-of-care costs and quality of care between CJR and non-CJR hospitals over the first two performance years.

DATA COLLECTION

We excluded 172 hospitals from our analysis due to their preexisting BPCI participation. We focused on elective admissions in the main analysis.

PRINCIPAL FINDINGS

While reductions in 90-day episode-of-care costs were greater among CJR hospitals (-$902, 95% CI: -$1305, -$499), largely driven by a 16.8% (p < 0.01) decline in 90-day spending in skilled nursing facilities, CJR hospitals significantly reduced the 90-day readmission rate (-3.9%; p < 0.05) and preferentially avoided patients aged 85 years or older (-5.9%; p < 0.01) and Black (-7.0%; p < 0.01). Cost reduction was greater in 2017 than in 2016, corresponding to the start of downside risk.

CONCLUSIONS

Participation in CJR was associated with a modest cost reduction and a reduction in 90-day readmission rates; however, we also observed evidence of preferential avoidance of older patients perceived as being higher risk among CJR hospitals.

Does Risk Mitigation Reduce 90-Day Complications in Patients Undergoing Total Knee Arthroplasty? A Cohort Study

Background

With ever-increasing demand for total knee arthroplasty (TKA), most healthcare systems around the world are concerned about its socioeconomic burden. Most centers have universally adopted well-defined clinical care pathways to minimize adverse outcomes, maximize volume, and limit costs. However, there are no prospective comparative trials reporting benefits of these risk mitigation (RM) strategies.

Methods

This is a prospective cohort study comparing post-TKA 90-day complications between patients undergoing RM before surgery and those following a standard protocol (SP). In the RM group, we used a 20-point checklist to screen for modifiable risk factors and evaluate the need for optimizing non-modifiable comorbidities. Only when optimization goals were achieved, patients were offered TKA.

Results

TKA was performed in 811 patients in the SP group and in 829 in the RM group, 40% of which were simultaneous bilateral TKA. In both groups, hypertension was the most prevalent comorbidity (48%), followed by diabetes (20%). A total of 43 (5.3%) procedure-related complications were seen over the 90-day postoperative period in the SP group, which was significantly greater than 26 (3.1%) seen in the RM group (p = 0.039). The commonest complication was pulmonary thromboembolic, 6 in each group. Blood transfusion rate was higher in the SP group (6%) than in the RM group (< 1%).

Conclusions

Screening and RM can reduce 90-day complications in patients undergoing TKA.

The Impact of Total Joint Arthroplasty on Long-Term Physical Activity: A Secondary Analysis of the Health and Retirement Study

OBJECTIVE

Physical inactivity is the fourth-leading cause of global mortality and is prevalent among people with lower extremity osteoarthritis. Lower extremity osteoarthritis is the most common arthritis type afflicting older adults, and total joint arthroplasty (TJA) performed to address the condition is Medicare's largest annual expense. Despite TJA intervention to address the disabling effects of osteoarthritis, physical activity (PA) level remains stable 6 months after TJA; however, the effect of TJA on long-term PA $(\ge$2 y) in a representative sample of older adults is unknown. The purpose of this study was to test the hypothesis that PA would remain stable in the long term.

METHODS

In this longitudinal observational study, a probability-weighted difference-in-differences analysis was conducted to observe the predictive margins of nontraumatic hip or knee TJA on levels of vigorous and moderate PA after 2 years. A combined Health and Retirement Study data set of community-dwelling adults who were >55 years old, had symptomatic osteoarthritis, and were in need of TJA between 2008 and 2018 (N = 4652) was used.

RESULTS

TJA was not associated with vigorous PA ($\delta$ = 2.37; SE = 5.23) or moderate PA ($\delta$ = -2.84; SE = 7.76) after 2 years.

CONCLUSION

TJA was not associated with increased long-term PA in older adults with osteoarthritis.

IMPACT

Physical therapists should not assume that there will be a natural increase in PA after functional recovery from TJA procedures. Older adults with lower extremity osteoarthritis may benefit from PA screening and promotion practices in physical therapy services.

LAY SUMMARY

Receiving a total joint replacement does not lead to increased physical activity levels 2 years after surgery.

Association of Social Behaviors With Community Discharge in Patients with Total Hip and Knee Replacement

OBJECTIVES

Understand the association between social determinants of health and community discharge after elective total joint arthroplasty.

DESIGN

Retrospective cohort design using Optum de-identified electronic health record dataset.

SETTING AND PARTICIPANTS

A total of 38 hospital networks and 18 non-network hospitals in the United States; 79,725 patients with total hip arthroplasty and 136,070 patients with total knee arthroplasty between 2011 and 2018.

METHODS

Logistic regression models were used to examine the association among pain, weight status, smoking status, alcohol use, substance disorder, and postsurgical community discharge, adjusted for patient demographics.

RESULTS

Mean ages for patients with hip and knee arthroplasty were 64.5 (SD 11.3) and 65.9 (SD 9.6) years; most patients were women (53.6%, 60.2%), respectively. The unadjusted community discharge rate was 82.8% after hip and 81.1% after knee arthroplasty. After adjusting for demographics, clinical factors, and behavioral factors, we found obesity [hip: odds ratio (OR) 0.81, 95% confidence interval (CI) 0.76-0.85; knee: OR 0.73, 95% CI 0.69-0.77], current smoking (hip: OR 0.82, 95% CI 0.77-0.88; knee: OR 0.90, 95% CI 0.85-0.95), and history of substance use disorder (hip: OR 0.55, 95% CI 0.50-0.60; knee: OR 0.57, 95% CI 0.53-0.62) were associated with lower odds of community discharge after hip and knee arthroplasty, respectively.

CONCLUSIONS AND IMPLICATIONS

Social determinants of health are associated with odds of community discharge after total hip and knee joint arthroplasty. Our findings demonstrate the value of using electronic health record data to analyze more granular patient factors associated with patient discharge location after total joint arthroplasty. Although bundled payment is increasing community discharge rates, post-acute care facilities must be prepared to manage more complex patients because odds of community discharge are diminished in those who are obese, smoking, or have a history of substance use disorder.

Overlap Between Medicare's Comprehensive Care for Joint Replacement Program and Accountable Care Organizations

BACKGROUND

Overlap between Medicare's Comprehensive Care for Joint Replacement (CJR) model and accountable care organizations (ACOs) may result in positive or negative synergies. In this study, we describe the overlap between the programs at the beneficiary and hospital levels.

METHODS

We conducted a retrospective study of patient and hospital characteristics using data from 2016 Medicare claims, the US Census Bureau, the American Hospital Association annual survey, Hospital Compare, and the Centers for Medicare & Medicaid Services Improving Medicare Post-Acute Care Transformation file. On the beneficiary level, we conducted 2 comparisons: (1) among patients who received joint replacement at CJR hospitals, ACO patients (overlap) vs not (CJR-only) and 2) among patients who received joint replacement elsewhere, ACO patients (ACO-only) vs not (neither). On the hospital level, we compared hospitals in the top quartile of overlap rate (high overlap) vs those in the bottom 3 (low overlap).

RESULTS

We studied 14,519 overlap, 38,972 CJR-only, 26,872 ACO-only, and 68,945 neither beneficiaries. Compared with CJR-only patients, the overlap group was less likely to be older than 85, of black race, of low socioeconomic status, and burdened with clinical complications. Similar results were observed when the ACO-only group was compared with the neither group. Compared with low overlap hospitals, high overlap ones were more likely to be of nonprofit and less likely to be of safety net.

CONCLUSION

CJR-ACO overlap is associated with differences in beneficiary and hospital characteristics, which raises key issues for providers and policymakers.

Variation of the Inpatient Cost of Care in the Treatment of Isolated Geriatric Intertrochanteric Hip Fractures

Introduction

Geriatric hip fractures are a major, costly public health issue, expected to increase in incidence and expense with the aging population. As healthcare transitions towards value-based care, understanding cost drivers of hip fracture treatment will be necessary to perform adequate risk adjustment. Historically, cost has been variable and difficult to determine. This study was purposed to identify variables that can predict the overall cost of care for geriatric intertrochanteric (IT) hip fractures and provide a better cost prediction to ensure the success of future bundled payment models.

Methods

A retrospective review of operatively-managed geriatric hip fractures was performed at single urban level I academic trauma center between 2013 and 2017. Patient variables were collected via the electronic medical record (EMR) including CCI, ACCI, ASA, overall length of stay (LOS), AO/OTA fracture classification and demographics. Direct and indirect costs were calculated by activity-based costing by the hospital's accounting software. Multivariable linear regression models evaluated which parameters predicted total inpatient cost of care.

Results

The mean cost of care was $19,822, ranging from $9,128 to $64,211. Critical care comprised 16.9% of total costs, followed by implant costs (13.6%), and nursing costs (12.6%). Regression analysis identified both ASA (p < 0.01) and ACCI (p = 0.01) as statistically significant associative parameters, but only LOS (r ² = 0.77) as a strong correlative measure for inpatient care cost.

Conclusion

This study found no correlation between ACCI or ASA and the total inpatient cost of care in isolated intertrochanteric geriatric hip fractures, suggesting that the inpatient episode-of-care costs cannot be accurately predicted by the patient demographics/comorbidities alone. Future bundled care payment models would have to be adjusted to account for variables beyond just patient characteristics.

Level of Evidence

Diagnostic Level IV.

How to Develop a Fair Revision Arthroplasty Bundle? Using Perioperative Complications and Readmissions to Investigate

BACKGROUND

The next frontier for value-based health care in total joint arthroplasty is revision surgery. Although the disparity in health care utilization between revision procedures compared with primary total hip and total knee arthroplasty (THA/TKA) procedures is recognized, no agreement regarding the risk adjustment necessary to make revision bundles fair to both payors and providers exists. The purpose of this study is to use the risk of perioperative complications and readmissions of patients undergoing revision THA/TKA to establish the foundations of a fair revision arthroplasty bundle.

METHODS

We retrospectively evaluated a consecutive series of 484 aseptic THA/TKA revisions performed at our institution over a 12-month period and compared complications, length of stay, reoperations, and 90-day readmissions to a group of 802 consecutive patients undergoing primary THA/TKA.

RESULTS

169 (34.9%) patients experienced major complications after revision THA/TKA compared with 176 (21.9%) patients undergoing primary THA/TKA (P < .001), (OR 1.91 CI 1.49-2.45, P < .001). Patients undergoing revision TKA were 3.64 times more likely to require hospitalization greater than 3 days (OR 2.59-5.12, CI 95%, P < .001), whereas patients undergoing revision THA were 4.46 times more likely to require hospitalization greater than 3 days (OR 2.89-6.87, CI 95%, P < .001). Revision patients were 3X more likely to have a 90-day readmission and 4X more likely to have a reoperation.

CONCLUSION

For a revision bundle to be fair and widely adopted, either significant financial incentive must be instituted or the latitude given to exclude outliers from the final reconciliation. This must be adjusted to not disincentivize institutions from providing care for failed hip and knee arthroplasties.

The Risk Assessment and Prediction Tool Accurately Predicts Discharge Destination After Revision Hip and Knee Arthroplasty

BACKGROUND

The Risk Assessment and Prediction Tool (RAPT) was developed and validated to predict discharge disposition after primary total hip and knee arthroplasty (THA/TKA). To date, there are no studies evaluating the applicability and accuracy of RAPT for revision THA/TKA. This study aims to determine the predictive accuracy of the RAPT for revision THA/TKA.

METHODS

Prospectively collected data from a single tertiary academic medical center were retrospectively analyzed for patients undergoing revision THA/TKA between January 2016 and July 2019. RAPT score was used to predict their postoperative discharge destination and its predictive accuracy was calculated. Patient risk (low, intermediate, and high) for postoperative inpatient rehabilitation facilities or skilled nursing facilities were determined based on the predictive accuracy of each RAPT score. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores.

RESULTS

A total of 716 consecutive revision THA/TKA episodes were analyzed. Overall, predictive accuracy of RAPT for discharge disposition was 83%. RAPT scores <3 and >8 were deemed high and low risk of discharge to a post-acute care facility, respectively. RAPT scores of 4 to 7 were still accurate 65%-71% of the time and were deemed to be intermediate-risk. RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition.

CONCLUSION

The RAPT has high predictive accuracy for discharge planning in revision THA/TKA patients. Patient-expected discharge destination is a powerful modulator of the RAPT score and we suggest that it be taken into consideration for preoperative discharge planning.

Medicare's Bundled Payments For Care Improvement Initiative Maintained Quality Of Care For Vulnerable Patients

The Bundled Payments for Care Improvement (BPCI) initiative established four models to test whether linking payments for an episode of care could reduce Medicare payments while maintaining or improving quality. Evaluations concluded that model 2, the largest, generally lowered payments without reducing quality for the average beneficiary, but these global results could mask adverse findings among vulnerable subpopulations. We analyzed changes in emergency department visits, unplanned hospital readmissions, and all-cause mortality within ninety days of hospital discharge among beneficiaries with one or more of three vulnerable characteristics-dementia, dual eligibility for Medicare and Medicaid, and recent institutional care-in 105,458 beneficiary episodes in the period October 2013-December 2016. The results for twelve types of medical and surgical BPCI episodes were evaluated relative to results in matched comparison groups. Our findings suggest that BPCI model 2 did not adversely affect care quality for beneficiaries with vulnerabilities. While this conclusion does not discourage the further development of bundled payment models, policy makers should support ongoing research to ensure that vulnerable populations are not adversely affected by these approaches.

Outpatient total knee arthroplasty: is it economically feasible in the hospital setting?

Background

With the removal of total knee arthroplasty (TKA) from the Medicare inpatient-only list, outpatient TKA can now be offered, irrespective of payer, in multiple sites. We compared time- and cost-effectiveness of outpatient TKA performed in a hospital outpatient department (HOPD) to that at an inpatient academic medical center (AMC).

Methods

We reviewed all outpatient TKAs performed at our AMC and our HOPD from August 2018 to July 2019. Time efficiency by phase of care was determined, and cost data were obtained from the hospital financial department. Patient selection for outpatient surgery was identical for each site of care.

Results

We identified 21 knees that had surgery at the HOPD and 65 knees that had surgery at the AMC. Demographics were similar in both groups. The AMC group had significantly longer in-facility to operating room (Δ (difference) = 33.5 minute, P = .0003), postanesthesia care unit to discharge (Δ = 158.8 minute, P < .0001) and in-facility to discharge (Δ = 199.3 minute, P < .0001) time periods compared to the HOPD group. The HOPD was significantly more cost-effective for the preoperative period (Δ = $75.7, P < .0001), postoperative period (Δ = $315.1, P < .0001), and total cost (Δ = $241, P < .0001).

Conclusions

Outpatient TKAs performed in an HOPD spend significantly less time within the facility than the ones performed in an AMC and cost significantly less. It is expected that approval of Medicare TKAs at ambulatory surgery centers will further improve cost and efficiency.

Arthroplasty Care Redesign Impacts the Predictive Accuracy of the Risk Assessment and Prediction Tool

BACKGROUND

The Risk Assessment and Prediction Tool (RAPT) is used to predict patient discharge disposition after total joint arthroplasty. Following a comprehensive, multidisciplinary redesign, our institution noticed a trend toward home discharge in patients with RAPT scores that historically predicted discharge to acute care facilities, presenting an opportunity to redefine the predictive ranges for RAPT.

METHODS

Retrospectively collected data were analyzed from a single institution in patients undergoing elective primary total joint arthroplasty from January 2016 to April 2017. Predictive accuracy (PA) was calculated for each RAPT score (1-12), RAPT score risk ranges (low, intermediate, and high), as well as overall. Other factors evaluated included patient-reported discharge expectation, body mass index, and American Society of Anesthesiologists scores as related to discharge disposition and the PA of RAPT.

RESULTS

Overall PA of RAPT was 88% (n = 1024 patients). Patients were high risk for acute care facility with a RAPT score of 1 to 3 (PA ≥ 83%), intermediate risk 4 to 7 (PA, 52%-79%), and low risk 8 to 12 (PA ≥ 89%). In multivariable analysis, RAPT score and patient-reported discharge expectation had the strongest correlation with actual discharge disposition.

CONCLUSION

Our multidisciplinary redesign has impacted the PA of RAPT. The original predictive ranges should be modified to reflect the increasing proportion of patients being discharged home following elective arthroplasty procedures. We have identified patient-expected discharge destination as a powerful modulator of the RAPT score and suggest that it be taken into consideration for discharge planning.

Gastrointestinal Complications Warranting Invasive Interventions Following Total Joint Arthroplasty

BACKGROUND

Gastrointestinal (GI) complications following total joint arthroplasty (TJA) are uncommon but can be associated with substantial morbidity and mortality. The current literature on GI complications that warrant invasive procedures after TJA is lacking. This study reviews the incidence and outcomes of GI complications after TJA that went on to require invasive procedures.

METHODS

All TJA patients at our institution between January 2012 and May 2018 who had GI complications requiring an invasive procedure within 30 days of TJA were identified and retrospectively chart reviewed. Descriptive statistics were used to evaluate these patients.

RESULTS

Of 19,090 TJAs in a 6-year period, 34 patients (0.18%) required invasive procedures for GI complications within 30 days of the index surgery. Twenty-two (64%) of the required procedures were endoscopy for suspected GI bleeding. Within this cohort, aspirin was the most common thromboprophylaxis used (63.6% of patients) and smoking was more prevalent (9.1% current smokers) (P = .28). Of the remaining 12 GI procedures required, 75% were exploratory laparotomies, 44.4% of which were performed for obstruction. Three (33.3%) of the exploratory laparotomy patients died during the study period.

CONCLUSION

GI complications necessitating surgical intervention after TJA are rare. Suspected GI bleeding is the most common indication for intervention and is typically managed endoscopically. Other complications, such as GI obstruction, often require more extensive intervention and open procedures. Though rare, GI complications following TJA can lead to detrimental outcomes, significant patient morbidity, and occasionally mortality; therefore, a heightened awareness of these complications is warranted.

Bundled Payment "Creep": Institutional Redesign for Primary Arthroplasty Positively Affects Revision Arthroplasty

BACKGROUND

Revision total joint arthroplasty (TJA) is associated with increased readmissions, complications, and expense compared to primary TJA. Bundled payment methods have been used to improve value of care in primary TJA, but little is known of their impact in revision TJA patients. The purpose of this study is to evaluate the impact of a care redesign for a bundled payment model for primary TJA on quality metrics for revision patients, despite absence of a targeted intervention for revisions.

METHODS

We compared quality metrics for all revision TJA patients including readmission rate, use of post-acute care facility after discharge, length of stay, and cost, between the year leading up to the redesign and the 2 years following its implementation. Changes in the primary TJA group over the same time period were also assessed for comparison.

RESULTS

Despite a volume increase of 37% over the study period, readmissions declined from 8.9% to 5.8%. Use of post-acute care facilities decreased from 42% to 24%. Length of stay went from 4.84 to 3.92 days. Cost of the hospital episode declined by 5%.

CONCLUSION

Our health system experienced a halo effect from our bundled payment-influenced care redesign, with revision TJA patients experiencing notable improvements in several quality metrics, though not as pronounced as in the primary TJA population. These changes benefitted the patients, the health system, and the payers. We attribute these positive changes to an altered institutional mindset, resulting from an invested and aligned care team, with active physician oversight over the care episode.

Transition to outpatient total hip and knee arthroplasty: experience at an academic tertiary care center

Background

Interest in outpatient total hip arthroplasty (THA) and total knee arthroplasty (TKA) has increased recently as part of value-based care and early recovery protocols. Outpatient pathways require significant paradigm shifts, are not used widely, and are mostly implemented at outpatient surgery centers or orthopedic specialty hospitals. In this article, we report on the outcomes of implementation of an outpatient arthroplasty protocol at a tertiary care academic medical center.

Methods

We performed a retrospective review on a series of 105 consecutive patients who underwent THA or TKA following our newly implemented outpatient arthroplasty protocol. We compared these patients to a group of inpatient arthroplasty patients from the same time period.

Results

Eighty-three of 105 (79%) patients were successfully discharged home on the day of surgery. Successful same-day discharge was predicted by early ambulation (P = .01), TKA over THA (P = .04), and shorter duration of surgery (P = .01). General anesthesia correlated with better early ambulation distances (P = .03) and a lower incidence of urinary retention (P = .049). The outpatient readmission and complication rates were 0.95% and 1.9%, respectively, whereas the matched inpatient rates were 3.7% and 2.9%, respectively.

Conclusions

Outpatient THA and TKA in a well-selected patient is feasible in an academic multidisciplinary tertiary care hospital, with complication rates approximating inpatient surgery. The findings reported here can be used to further optimize outpatient arthroplasty protocols.